USCDI Export for the Public
Classification Level Sort descending | Data Class | Data Class Description | Data Element | Data Element Description | Applicable Standards | Submitter Name | Submitter Organization | Submission Date |
---|---|---|---|---|---|---|---|---|
Level 0 | Care Team Members | Information about a person who participates or is expected to participate in the care of a patient. |
Proxy Decision Maker | Individual designated by the patient to make healthcare decisions for the patient in the event the patient is unable. |
Holly Miller, MD | MedAllies | ||
Level 0 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Audiogram | Standard under development by HL7 in Diagnostic Audiology Reporting HL7 V2 Implementation Guide |
Troy Kaji | Contra Costa Health Services | ||
Level 0 | Laboratory | Analysis of clinical specimens to obtain information about the health of a patient. |
Accession number | The unique identifier for a single instance of a specimen received by a laboratory and its analysis. |
Riki Merrick | Association of Public Health Laboratories | ||
Level 0 | Cancer Care | Radiation Therapy Outcome/Disease Status | Status of the disease treated with radiation therapy at the time of the record. Under Treatment No evidence of disease (NED) Stable Disease Partial Response Progressive Disease Indeterminate (possible pseudo-progression) Complete Response Biochemical Recurrence Primary Recurrence Local Recurrence Nodal Recurrence Distant Recurrence In OORO for each instance record of a Cancer Patient Treatment Outcome, multiple values of Disease Status can be selected e.g. Biochemical Recurrence, Nodal Recurrence |
Charles Mayo | University of Michigan | |||
Level 0 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Visual Acuity | Narrative clinical assessment of the Visual Acuity evaluation. |
Please see suggestions from attached Excel document |
|||
Level 0 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Visual Fields | Narrative clinical assessment of the Visual Fields evaluation. |
Please see suggestions from attached Excel document |
Melissa Ayres | SSA | |
Level 0 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Holter monitor | Narrative clinical assessment of the Holter monitor results. |
Please see suggestions from attached Excel document |
Melissa Ayres | SSA | |
Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Physical Exam | Narrative clinical assessment of the Physical Exam results. |
Please see suggestions from attached Excel document |
Melissa Ayres | SSA | |
Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Genetic Testing | Narrative clinical assessment of the Genetic Testing results. |
Please see suggestions from attached Excel document |
Melissa Ayres | SSA | |
Level 0 | Health Status Assessments | Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s family, or patient’s healthcare provider that could identify a need, problem, or condition. |
Mental Status Evaluation | Narrative clinical assessment of the Mental Status Evaluation. |
Please see suggestions from attached Excel document |
Melissa Ayres | SSA | |
Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Neuropsychological Testing | Narrative clinical assessment of the Neuropsychological Testing results. |
Please see suggestions from attached Excel document |
Melissa Ayres | SSA | |
Level 0 | Clinical Notes | Narrative patient data relevant to the context identified by note types.
|
Psychological Testing | Narrative clinical assessment of the Psychological Testing results. |
Please see suggestions from attached Excel document |
Melissa Ayres | SSA | |
Level 0 | Cancer Care | Pathology Molecular Test Result | Score for the molecular test result identified. For example Pathology Molecular Test Name is ProMark, Result could be 30 |
American Joint Committee on Cancer e.g. AJCC8 |
Charles Mayo, PhD | University of Michigan | ||
Level 0 | Cancer Care | Radiation Therapy Course Target Dose Volume | Name of target volume structure for radiation therapy (e.g. Prostate). |
Elizabeth Covington | University of Michigan | |||
Level 0 | Cancer Care | Radiation Therapy Course Target Dose Volume | Identify targets and overall doses treated with the radiation therapy course. This supports systematic reporting what was done for treatment summaries. For example it enables identifying that the prostate received a dose of 7200 cGy. Where the prescription reflects intent, this element reflects what was delivered. |
Elizabeth Covington | University of Michigan | |||
Level 0 | Cancer Care | Radiation Therapy Course - Involves Reirradiation | Does the radiation field for the current course overlap with radiation fields from prior courses of therapy? |
Elizabeth Covington | University of Michigan | |||
Level 0 | Cancer Care | Radiation Therapy Course Number Of Sessions in Course | Total number of sessions in the treatment course. A session is the period between when the patient enters the treatment room and when they leave it. |
Elizabeth Covington | University of Michigan | |||
Level 0 | Cancer Care | Provider Reported Toxicity Value | For each Cancer Patient - Provider Reported Toxicity record the Toxicity Value corresponding to the Toxicity Measure specified indicates the severity of the toxicity using the standardized table. specifies what value is measured. For example if CTCAE v5.0 (https://ctep.cancer.gov/protocoldevelopment/electronic_applications/doc…) the values in the standardized set are 0,1,2,3,4,5 The AAPM Operational Ontology for Radiation Oncology ( https://aapmbdsc.azurewebsites.net) identified this as a high priority element supporting patient care, outcomes research and public policy |
Common Terminology Criteria for Adverse Events |
Charles Mayo | University of Michigan | ||
Level 0 | Cancer Care | Provider Reported Toxicity Measure | For each Cancer Patient - Provider Reported Toxicity record the Toxicity Measure specifies what value is measured. For example if CTCAE v5.0 (https://ctep.cancer.gov/protocoldevelopment/electronic_applications/doc…) is used then the Toxicity Measure would correspond to CTCAE Term (e.g. Dry Mouth, or Dry Mouth) The AAPM Operational Ontology for Radiation Oncology ( https://aapmbdsc.azurewebsites.net) identified this as a high priority element supporting patient care, outcomes research and public policy |
Common Terminology Criteria for Adverse Events |
Charles Mayo | University of Michigan | ||
Level 0 | Clinical Tests | Non-imaging and non-laboratory tests performed that result in structured or unstructured findings specific to the patient to facilitate the diagnosis and management of conditions. |
Endoscopy | Narrative clinical assessment of the Endoscopy results. |
Please see suggestions from attached Excel document |
Melissa Ayres | SSA |